MINNEAPOLIS (AP) — The Minneapolis Veterans Medical Center was “deficient” in its handling of a suicidal Vietnam War veteran who killed himself while under the agency’s care, according to a recent report by the national Veterans Administration office.

The one-time Marine had survived a recent suicide attempt, and mental health staff warned that he might attempt suicide again. But the hospital failed to follow up, according to the report from the VA Inspector General’s office.

“While we cannot say whether implementation of [recommended] measures would have changed the outcome of this case, the facility nonetheless did not adhere to [VA] guidelines on managing this patient at high risk of suicide,” the report said.

Ralph Heussner, a spokesman for the Minneapolis VA, said the hospital has since improved communication between departments about high-risk patients and updated its suicide-prevention training and policies.

“Every veteran’s suicide is a tragedy and we appreciate the review of this incident,” Heussner said. “We will use this information to improve our system of flagging potential risks.”

The report doesn’t name the veteran, but relatives of Raymond Schwirtz confirmed the investigation was launched at their request, according to the Minneapolis Star Tribune.

Schwirtz served in the Marines between 1971 and 1975. He was on full disability from illnesses that included multiple sclerosis, depression and chronic pain.

In January 2011 he told a VA therapist he was feeling depressed but that he wasn’t likely to hurt himself because of the effect it might have on his family. Five days later, he was hospitalized after he cut his throat.

Two days after he left the hospital, he went to the Minneapolis VA for a checkup. He confirmed the suicide attempt to a nurse and was admitted. Two staff members conducted suicide-risk assessments and concluded that his risk level was “heightened.”

He was discharged after three weeks and had occasional contact with the VA over the next several months.

Schwirtz died in June 2011 after he doused himself with gasoline and lit himself on fire.

The recent report marks the second time in a year that the Minneapolis VA has been criticized for how it handled suicidal veterans.

Last summer, the Minneapolis VA turned away an Iraq war veteran who reported hearing voices and feeling suicidal. VA doctors examined him and determined he wasn’t a threat to himself or others. Four days later, while still hearing voices, he stole a car and was struck and injured after he ran in front of a van.